Int J STD AIDS OnlineFirst, published on August 29, 2016 as doi:10.

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Original research article

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Guyana: Utility of the Health Belief Model

Deborah Vitalis

Abstract
Barriers to antiretroviral therapy (ART) adherence among pregnant women are varied and complex. This study explored
the constructs of a theoretical model, the Health Belief Model (HBM) to understand and predict ART adherence among
pregnant women in Guyana. A cross-sectional study surveyed 108 pregnant women attending 11 primary care clinics.
ART adherence ranging from the past weekend to three months was assessed through self-reports, and health beliefs
with the Adherence Determinants Questionnaire (ADQ). Constructs with sufficient variation in responses were tested
for association with the level of adherence using Spearman’s rank correlation coefficient and test. Sixty-seven per cent
(72) of the women reported being always adherent. Although there was positive endorsement of ART treatment and
adherence, the HBM did not help in understanding or predicting ART adherence in this population. Only one item from
the perceived susceptibility construct was significantly associated (p ¼ 0.009) with adherence. Interventions are war-
ranted to address ART adherence in this population, as 19% of the women were recently non-adherent. Although the
ADQ did not contribute to a deeper understanding or provide insight into pathways that can be targeted for interven-
tion, theoretical models can play a key role in identifying these pathways.

Keywords
ART, adherence, pregnant women, HIV, Caribbean

Date received: 3 February 2016; accepted: 2 August 2016

Introduction science theory to provide the necessary concepts to

The Caribbean region has an estimated adult HIV preva-
lence of 1.1%1, the second highest after Sub-Saharan
Africa. Guyana’s adult HIV prevalence is 1.4%2 in the
general population and 1.9%2 among pregnant women,
with women accounting for an estimated 58.1%1 of all
persons living with HIV.
Antiretroviral therapy (ART) use during pregnancy
has contributed to significant reductions in vertical
transmission rates as well as improvements in maternal
health with overall reductions in morbidity and mortal-
ity. However, treatment efficacy requires high levels
of adherence. Recent studies indicate that pregnant
women are still not achieving the required optimal
adherence levels.3,4 Barriers to adherence in this popu-
lation are varied, and as such, strategies to understand
the factors related to poor adherence are important to
inform appropriate interventions for optimal maternal
and infant health outcomes. The development of suc-
cessful interventions requires information on the pre-
dictors of ART adherence grounded in behavioural
either change or reinforce behaviour.5
Theoretical context
In general, behavioural theory is important in identify-
ing processes through which health decisions are made,
thus providing insights and explanations about health
outcomes. By uncovering these mechanisms and how
they work, they offer more effective behaviour change
strategies. Behavioural risks such as non-adherence to
medication or medical advice, risky sexual activities or
the inability to engage in health promotion have serious
implications for public health.6 Similarly, the use of
Department of Infection and Population Health, University College
London, London, UK
Corresponding author:
Deborah Vitalis, Department of Infection and Population Health,
University College London, London, UK.
Email: dmvitalis@gmail.com

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2 International Journal of STD & AIDS 0(0)
theory for HIV and AIDS prevention can assist in iden-
tifying characteristics that play a role in predicting and
understanding behaviour. Theory-based interventions
can provide the tools for reducing risky behaviour
and maintaining healthy habits.7,8
The Health Belief Model (HBM) was selected as the
theoretical model for this study, since it is one of the most
widely used frameworks in health behaviour research for
understanding and predicting adherence behaviour to
health advice.9,10 The HBM which dates back to the
1950s11 has been used to explain and guide interventions
to change health behaviour including adherence in
chronic health diseases such as HIV,12–15 and emphasizes
the role of several factors: (1) perceived severity of a dis-
ease; (2) perceived susceptibility of an individual to that
disease or susceptibility to disease progression; (3) per-
ceived benefits linked with health behaviour to combat
the disease; (4) perceived barriers to practicing the health
behaviour; (5) cues to action; and (6) self-efficacy.
Perceived severity deals with a person’s belief about the
medical, clinical, and social consequences of contracting
an illness or leaving it untreated; perceived susceptibility
refers to a person’s belief that s/he is at risk of contracting
an illness or worsening of the condition; perceived benefits
address a person’s beliefs about the efficacy and feasibility
of a particular action for treating or preventing illness;
perceived barriers refer to a person’s beliefs about the
problems s/he may face while trying to perform a health
behaviour and weighing the benefits against the negatives;
cues are either internal or external triggers resulting in a
course of action; and self-efficacy refers to a person’s con-
fidence in his/her ability to successfully execute the action.
The HBM constructs can help to predict the rationale
for prevention and control of ill health. It is based on the
assumption that persons will change their behaviour if
they believe that their health is at risk and their actions
could lead to adverse consequences.6,9,11 In terms of
adherence to HIV medication, the HBM predicts that
adherence is more likely to occur if the individual under-
stands the gravity of their illness, the possibility of
advanced HIV disease, the benefits of ARV treatment
and the negative consequences of prematurely disconti-
nuing treatment.9,16 Although many studies on ART
adherence have been conducted worldwide,17–21 few
research studies have incorporated the HBM as a theor-
etical framework for ART adherence, and none have
been conducted in Guyana and the wider Caribbean
region.10,12–14 Despite its strength, some deficiencies of
the HBM include its emphasis on individual perceptions
without consideration of behavioural skills and social
or environmental factors.9,22,60 Notwithstanding these
criticisms, the HBM has been used to predict patient
adherence.9,23,24 In a review of studies utilizing the
HBM over a 10-year period (1974–1984), Janz and
Becker9 indicated that research conducted during that
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period validates the use of the HBM as a tool for inter-
preting persons’ decisions on health matters. However,
they posited that more research needs to be done to
streamline the instruments used to measure its constructs.
A literature search for Caribbean studies of ART
adherence on PubMed and the HIV Gateway database
of Caribbean HIV research25 yielded 15 peer-reviewed
journal articles and abstracts presented at international
conferences.18,19,26–38 None focused on ART adherence
in pregnancy, none were from Guyana, and none
included a theoretical framework (Table 1). Factors
found to be associated with ART adherence included:
support from family, friends or healthcare providers;
being married or co-habiting; satisfaction with the
health system; and adherence counselling. Barriers to
adherence included: medication side effects; alcohol
use; mental health issues such as depression; stigma;
lack of food; and being away from home.
This study was conducted to explore the constructs
of the HBM to understand and predict adherence to
ART among pregnant women in Guyana, and to the
author’s knowledge is the first study to examine the
HBM among HIV-positive pregnant women in general
and Guyana specifically.
Methods
Study setting
The study was conducted at 11 sites (West Demerara
Regional Hospital, Campbellville Health Centre,
Dorothy Bailey Health Centre, Georgetown Public
Hospital Corporation, Beterverwagting Health Centre,
East La Penitence Health Centre, Davis Memorial
Hospital, Mercy Hospital, New Amsterdam Health
Centre, Cumberland Health Centre and Bohemia Health
Centre) within three of the ten Administrative Regions of
Guyana – regions 3, 4 and 6. Region 4 is the most heavily
populated region, with 41.3% of the population, and the
three regions contribute to 71.6% of the total population
and 88.2% of reported HIV cases.2 All study sites provide
HIV treatment and care services free-of-charge, and also
provide primary health care to the general population.
Sampling
The study sites in Regions 3, 4 and 6 were the sites with
the highest numbers of the study population during the
data collection period, and it is thought that most eli-
gible women attending there in the period were
recruited to the study, providing a broadly representa-
tive sample of the study population. Eligibility
included: being at least 16 years of age; initiating
ART prior to or in the current pregnancy; and being
capable of giving consent. The author was facilitated by
Vitalis 3

Table 1. Published articles and conference abstracts from Caribbean region.

Theoretical Adherence Non-adherence

Author Country Population constructs factors factors

1 Harvey et al.18a Jamaica PLHIV None 54.8%  95% Adherent; Being away from home;
37.5% 80–84% adher- sleeping through dose
ent; 7.7% < 80% time; forgetting; and
out of pills
2 Allen et al.19a Antigua and Barbuda; PLHIV None 70% with 95% Alcohol use; side effects
Grenada; Trinidad Adherence;
and Tobago Counselling increased
adherence
3 Malow et al.34a Haiti PLHIV None 85% Reported perfect Depression; negative atti-
adherence tudes about ART
4 Saxena et al.26 Haiti PLHIV None 83% Reported perfect Anxiety, concerns about
adherence; females ART, contributed to
more non-adherent non-adherence
than males
5 Beckford-Jarrett et al.27 Jamaica PLHIV None Not available PTSD had adverse effect
on adherence
6 Abreu Perez et al.28 Dominican PLHIV None Married or co-habitation 66% Non-adherent to
Republic contributed to ART; difficult to take
adherence ART in the morning
7 Benitez et al.29 Dominican PLHIV None 35% Completely adherent Not available
Republic to ART; family support
enhanced adherence
8 Aragones et al.36a Cuba PLHIV None 71% High adherence; Not available
good relationship with
doctor; self-efficacy;
confidence in health
system was associated
with high adherence
9 Smith30 Bahamas PLHIV None Not available Access to clinic and phar-
macy; ART schedule
and side effects; stigma;
lack of food contribu-
ted to non-adherence
10 Harris et al.36a Dominican Republic PLHIV None 76% Reported high Heavy alcohol use; having
adherence children; perceptions of
less social support
contributed to non-
adherence
11 Aragones Lopez et al.31 Cuba PLHIV None 63% Perfect adherence; Not available
relationship with
doctor and support
from family, friends and
co-workers contribu-
ted to adherence
12 Smith et al.32 Guyana PLHIV None 83% with  95% Depression had adverse
Adherence effect on adherence
13 Harvey et al.33a Jamaica PLHIV None 55% with  95% Being away from home;
Adherence sleeping through dose
time; forgetting; run-
ning out of pills; no
food; side effects con-
tributed to non-
adherence
(continued)

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4 International Journal of STD & AIDS 0(0)
Table 1. Continued.
Author Country
14 Williams et al.37a Jamaica
15 Duke et al.38 Trinidad and
Tobago
ART: antiretroviral therapy; PLHIV: people living with HIV.
a
Published journal articles.
the nurse supervisor to identify patients typical of the
target group.
Data collection
A cross-sectional survey was conducted with data being
collected between August 2012 and August 2013
using interviewer-administered questionnaires. Ethical
approval was obtained from University College London
Research Ethics Committee in the United Kingdom, and
the Guyana Ministry of Health Institutional Review
Board. Written informed consent was obtained from all
participants.
Measures
Adherence. The ART adherence measure was based on
an adaptation of the Adult AIDS Clinical Trials Group
adherence instrument by Chesney and colleagues.40
Questions queried both recent non-adherence (past
four days, weekend) and distal adherence (past three
months). Self-reports were used to measure adher-
ence based on three ordered categories: recent non-
adherence (persons who missed doses in the past four
days or weekend); recent adherence, but distal non-
adherence (persons who did not miss doses in the past
four days or at the weekend but missed from the past
week to three months); and always adherent (persons
who had never missed any doses in the past week, week-
end or three months).
Health beliefs. The adherence determinants question-
naire (ADQ) was first developed and validated to
assess factors related to cancer control by DiMatteo
et al.41 It consists of seven subscales and a total of 38
Likert scale statements varying from 1 (strongly dis-
agree) to 5 (strongly agree). The seven subscales
include: interpersonal care and relationship with
healthcare providers; perceived utility of treatment;
perceived severity of illness; perceived susceptibility to
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Theoretical Adherence Non-adherence
Population constructs factors factors
PLHIV None 58% Adherent to ART Leaving tabs at home; for-
getting; duration of
ART
PLHIV None Not available 64.8% K103 mutation;
75.6% M184 mutation;
62% resistant to
tenofovir
illness progression; subjective norms (beliefs that family
and friends support adherence to treatment plan);
intentions to comply with treatment; and support/bar-
riers to adherence. The ADQ perceived susceptibility
subscale comprised three questions such as ‘No
matter what I do, there’s a good chance of my HIV
getting worse’. The perceived severity subscale con-
sisted of four questions which included ‘There are
many diseases more severe than HIV’. The perceived
benefits construct comprised four questions measuring
benefits of ARV treatment such as ‘The benefits of my
treatment plan outweigh any problems I might have in
following it’. Perceived barriers consisted of four ques-
tions such as ‘Lots of things get in the way of following
my treatment plan’. Items were reverse-scored where
appropriate to produce a total score, where higher
scores were indicative of greater perceptions. The inter-
nal consistency reliability coefficient for the full seven
subscales was a ¼ 0.48, with alphas of 0.5, 0.3, 0.1 and
0.4 for perceived susceptibility, perceived severity, per-
ceived benefits and perceived barriers respectively.
To facilitate comparison among the subscales, scores
were linearly transformed to a 0–100 scale. The HBM
constructs of perceived susceptibility, perceived bar-
riers, perceived benefits and perceived severity were
assessed with the other three constructs from the ADQ.
Other measures. Additional data were collected on
socio-demographic and clinical characteristics includ-
ing age, race, religion, education, marital status,
income, treatment regimen and CD4 T cell count.
Statistical analyses
Data were analysed using Stata IC13.42 The original five-
point Likert scale ranging from ‘strongly disagree’ (1) to
‘strongly agree’ (5) was regrouped into three response
categories of ‘Disagree’, ‘Neither’, and ‘Agree’ because
of the small numbers within the various response cate-
gories. Spearman’s rank correlation coefficient and test
Vitalis 5

was utilised to examine the relationship between the Table 2. Continued.

ADQ constructs and levels of adherence. HIV-infected
Characteristic n (%)

Results Home ownership

Own-home 65 (60.2)
Characteristics of participants Rental 25 (23.2)
The study achieved a high response rate as out of the Other 18 (16.7)
111 patients eligible for the study, 108 agreed to par- Live births
ticipate (97%) and completed the questionnaire. Those 0 24 (22.2)
who declined did not differ in terms of demographics 1–2 40 (37.0)
and other key characteristics. Over 50% of the women >2 44 (40.7)
were aged 25–34 years, with the majority (77%) having Gestation (weeks)
at least a secondary school education. Most partici- First trimester (0–13) 5 (4.6)
pants (68%) had been on ART prior to the current
Second trimester (14–26) 49 (45.4)
pregnancy, and about 75% were prescribed a fixed-
Third trimester (27þ) 54 (50.0)
dose combination drug, Atripla. Full characteristics
of participants are displayed in Table 2. Parity
Primiparous 24 (22.2)
Multiparous 84 (77.8)
Planned/wanted pregnancy
Table 2. Characteristics of HIV-positive pregnant women. Wanted 31 (28.7)
HIV-infected Unwanted 77 (71.3)
Characteristic n (%) ART prescribed in current pregnancy
Yes 35 (32.4)
Age
No 73 (67.6)
15–24 28 (25.9)
Time on ART (weeks)
25–34 63 (58.3)
Median, IQR 52, 5–208
35–44 17 (15.7)
CD4 count
Race
350 33 (31.1)
African 49 (45.4)
351–500 27 (25.5)
Mixed 44 (40.7)
>500 46 (43.4)
East Indian 12 (11.1)
ART regimen
Other 3 (2.8)
Atripla 82 (75.9)
Religion
Truvada þ NVP 10 (9.3)
Christian 98 (90.7)
Combivir þ NVP 6 (5.6)
Non-Christian 10 (9.3)
Truvada þ AZT þ LPV/r 5 (4.6)
Education
Combivir þ LPV/r 4 (3.7)
None–primary 16 (14.8)
Combivir þ EFV 1 (0.9)
Secondary 83 (76.9)
Post-secondary–University 9 (8.3) ART: antiretroviral therapy.
Marital status
Single 36 (33.3)
Married 13 (12.0) ART adherence and health beliefs
Common-law 59 (54.6)
Employed Adherence levels for the women were distributed as
Yes 49 (45.4)
follows: recent non-adherence (19%); recent adherence,
but distal non-adherence (15%); and always adherent
No 59 (54.6)
(67%), with 34% being non-adherent. Based on the
Income – main source
distribution of individual responses to the seven
Family 10 (9.3) ADQ constructs, only perceived susceptibility and per-
Job 49 (45.4) ceived severity had sufficient variation in responses
Partner 49 (45.4) to warrant further examination for associations with
(continued) adherence.

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6 International Journal of STD & AIDS 0(0)

Perceived severity and susceptibility Discussion

There were no significant associations between the per-
ceived severity items and adherence as depicted in
Table 3. The distribution of the responses for perceived
susceptibility to advanced HIV disease for all three
items of the construct was skewed in the direction of
positive endorsement of adherence (Table 3). Only D3
‘My body will fight off HIV in the future’ displayed a
significant association with adherence (p ¼ 0.009), sug-
gesting greater adherence in women who agreed more
with the idea that their body will fight off HIV in the
future. This association was surprising as recent non-
adherence was higher among women who neither
agreed nor disagreed (43%) with the statement.
These findings indicate that achieving adequate ART
adherence levels is a challenge for this group of preg-
nant women, as only 67% were always adherent and
19% were recently non-adherent. The studies by
Mepham et al.20 and Nachega et al.3 among pregnant
women in other settings have identified adherence levels
of 61% and 74%, respectively. Rates ranging from
55% to 90% have been identified among PLHIV in
the Caribbean region,18,19,35,37 with data from a
Guyana abstract identifying 83% PLHIV with 95%
adherence32 albeit different measures and definitions of
adherence were applied and none of the studies were
among pregnant women.

Table 3. Distribution of health beliefs and adherencea.

Construct Scale Adherence, % (n)

Recent Recent Always

non-adherence adherence adherent p

Perceived susceptibility
D1. Expect to be free of HIV in the future Disagree 20 (1) 0 (0) 80 (4) rs ¼ 0.10,
p ¼ 0.31
Neither 42 (5) 8 (1) 50 (6)
Agree 15 (14) 16 (15) 68 (62)
D2. Good chance of HIV getting worse Disagree 16 (15) 15 (14) 69 (66) rs ¼ 0.16
p ¼ 0.10
Neither 71 (5) 14 (1) 14 (1)
Agree 0 (0) 17 (1) 83 (5)
D3. Body will fight off HIV in the future Disagree 30 (3) 20 (2) 50 (5) rs ¼ 0.25,
p ¼ 0.009*
Neither 43 (6) 14 (2) 43 (6)
Agree 13 (11) 14 (12) 73 (61)
Perceived severity
C1. Many diseases more severe than HIV Disagree 14 (3) 9 (2) 77 (17) rs ¼ 0.15
p ¼ 0.11
Neither 13 (1) 0 (0) 88 (7)
Agree 21 (16) 18 (14) 62 (48)
C2. HIV is not as bad as people say Disagree 15 (8) 19 (10) 67 (36) rs ¼ 0.05
p ¼ 0.64
Neither 11 (1) 11 (1) 78 (7)
Agree 24 (11) 11 (5) 64 (29)
C3. HIV is a terrible disease Disagree 17 (6) 25 (9) 58 (21) rs ¼ 0.09
p ¼ 0.35
Neither 29 (2) 0 (0) 71 (5)
Agree 18 (12) 11 (7) 71 (46)
C4. Little hope for people with HIV Disagree 20 (18) 16 (14) 64 (56) rs ¼ 0.13
p ¼ 0.18
Neither 0 (0) 0 (0) 100 (3)
Agree 12 (2) 12 (2) 76 (13)
a
Spearman’s rank correlation coefficient and test; *statistically significant test.

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Vitalis
However, the fact that 19% of the women in the
survey were recently non-adherent is a worrying finding
as this action not only compromises their own health
but also that of the child. Moreover, as this was a cross-
sectional survey, this proportion may not truly reflect
adherence behaviour, as adherence levels could have
fluctuated with the possibility that many more women
were non-adherent at other times in the pregnancy, imply-
ing that levels of non-adherence may be underestimated
and could be much higher in this group. Longitudinal
studies are warranted to determine the magnitude of
these issues, followed by appropriate interventions.
The HBM was selected as the theoretical framework
in this study to gain an understanding of and predict
adherence to ART medication among pregnant women.
However, these HBM constructs as operationalised by
the ADQ did not seem to provide much insight into
ART adherence, although overall the women indicated
positive endorsement of treatment and adherence.
Although the HBM has been used in other populations
and settings, this study is the first of its kind among
HIV-positive pregnant women. Only one item from the
perceived susceptibility construct, D3 ‘Body will fight
off HIV in the future’ was significantly associated with
adherence. However, due to the number of statistical
tests performed on the data, this association might be
attributed to chance.
The HBM has had mixed reviews in terms of pre-
dicting treatment adherence. Barclay et al.14 examined
the use of the HBM to predict adherence among 185
HIV-positive adults with the HBM components of the
ADQ. Their findings indicated that perceived suscepti-
bility and perceived severity were unrelated to adher-
ence in adults over 50 years. However, perceived
benefits predicted poor adherence within the younger
cohort. Another study by Turner et al.15 on predictors
of adherence among 89 veterans with multiple sclerosis
using four HBM constructs found that only perceived
benefits predicted adherence. Gao et al.’s10 study on
health beliefs, disease severity, and adherence among
72 HIV-positive participants found two constructs (per-
ceived susceptibility, perceived barriers) significantly
related to ART adherence.
One of the criticisms of the HBM is that there is no
standard tool to measure the constructs, and all of the
studies highlighted in the discussion section used differ-
ent measures of analysis. Blackwell16 and Munro
et al.22 contend that the HBM is not a reliable tool
for predicting adherence as it produces inconsistent
results when used in risk-reduction behaviours ‘linked
to more socially determined or unconscious behaviours
(Blackwell,16 p.165).
Another model worth considering in understanding
the women’s adherence is Fishbein’s integrative model
(IM) for behavioural prediction, an updated model for
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7
the theories of reasoned action and planned behav-
iour.5,43 Fishbein argues that this framework can be
used to explain all types of behaviours and includes
the constructs of intentions, environmental constraints
and skills/abilities. This model includes the construct of
environmental constraints which is one of the deficien-
cies of the HBM. The construct of self-efficacy which
originates from Bandura’s Social Cognitive theory is
described as a key component for both initiating and
maintaining behaviour change, as it measures the abil-
ity to successfully achieve an outcome.44,45 Self-efficacy
(not measured in this study) was not originally a con-
struct of the four original HBM components, but was
later added on to the model.9,22 It is also a component
of other health behaviour models, such as the IM dis-
cussed above. Several studies have identified a relation-
ship between self-efficacy and adherence, whereby
higher self-efficacy predicted better adherence.46–48 As
such, the role that this construct plays in the adherence
behaviour of this population warrants some attention.
While the Caribbean literature to date has identified
environmental and skills factors (mental health, forget-
ting, medication side effects, lack of self-efficacy and
food insecurity) adversely impacting adherence, the
use of appropriate interventions guided by randomised
control trials (RCTs) have not been undertaken.
Evidence from RCTs and observational studies, pri-
marily conducted in resource-limited settings in
Africa, provide support for simple or low-cost interven-
tions such as use of mobile phone short messaging
system, reminder phone calls, counselling and educa-
tion, and peer treatment supporters.49–54 The use of
theory to inform this type of research can only
strengthen the work already documented via the epi-
demiological approach to yield additional benefits in
understanding health behaviour, given the unique cul-
tural, socio-economic, and health system factors con-
fronting the Caribbean region.
Further research work is needed to validate screen-
ing tools for adherence and mental health issues, par-
ticularly depression, given what has been highlighted in
this study and other Caribbean literature.
Strengths and limitations
One of the strengths of this study is that this was
the first time the constructs of the HBM were used to
examine ART adherence in a pregnant HIV-positive
population in Guyana, as well as a low-middle
income country.
As this was a cross-sectional study, the associations
identified among the variables can only be considered
correlations and may not be causal. The small number
of responses (<10) for some questions of the ADQ may
have limited the ability to detect possible associations
8 International Journal of STD & AIDS 0(0)
with adherence due to limited variance. There was com-
plete endorsement of a single response category for
many items of the ADQ. Further, multiple comparison
tests of the data may have increased the probability of a
type 1 error.
Use of a five-point Likert scale may not be appro-
priate for use in this population as the subtle differences
in scale items agree/strongly agree may have been con-
fusing. Future studies in this population utilizing,
for example, a three-point scale using agree, disagree
and neither should be undertaken.
The study was based on self-reports of adherence
which may be compromised by either lapses in recall
or the tendency for a socially acceptable response.
However, prior ART studies have found them to be
a reliable measurement tool, as results have significantly
correlated with other data such as serum levels (viral
load, CD4 cell count), MEMS, and pharmacy data.55–58
Conclusion
Although some constructs of the HBM have predicted
medication adherence, in this study, however, the use of
the ADQ scale as a proxy for the HBM constructs did
not seem to help in understanding or predicting adher-
ence in this population. The HBM constructs were gen-
erally not found to be associated with adherence, with
the lone construct associated producing counter-intui-
tive results. The HBM as a theoretical model and the
ADQ may not be worthwhile tools to help understand
or predict adherence in this population, and might be
inadequate or inappropriate for this cultural setting.
Many ADQ item responses reflected overwhelming
positive endorsement for treatment adherence, raising
concerns about the ability of the ADQ to properly
measure the HBM or its ability to measure these con-
structs within this population.
Moreover, these results suggest that individual atti-
tudes are of very limited use in explaining adherence and
are not primary ART adherence determinants based on
the findings from this study, and existing literature from
Africa and the Caribbean which tend to indicate that
psychological, environmental and socio-cultural factors
may be more important. Finally, because adherence is a
key factor to achieving UNAIDS’ ambitious target of an
AIDS-free generation in low- and middle-income coun-
tries by 2030,59 we need to continue to determine its
predictors to better define our interventions. Further
testing of this model in this population is warranted
with a more simplified Likert scale and a weighting on
the construct of susceptibility. Although the tools (ADQ)
used to measure the HBM did not contribute to a deeper
understanding or provide insight into pathways that can
be targeted for intervention, theoretical models play a
key role in identifying these pathways.
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Acknowledgements
The author would like to express profound gratitude to the
women who participated in this study. Special thanks to
Lorraine Sherr, Zelee Hill, and Andrew Copas of University
College London and the anonymous reviewers for construct-
ive feedback.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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